Employment Application

We are experiencing temporary technical issues that may prevent your online job application from being submitted successfully. In the meantime, please print out a paper application (see Employment Application button above) and either mail to or drop off at 2107 Main Street, PO Box 567, Emmetsburg, Iowa 50536”

(If offered employment, you will be required to provide documentation to verify eligibility.)

BACKGROUND INFORMATION

Do you have a record of founded child or dependent adult abuse?

If you have, please give details?

Have you ever been convicted of a crime, in this or any other state?(Conviction does not constitute an automatic bar to employment)

If the conviction or record is from a state other than Iowa, please list

Do you have or are you eligible to obtain a valid Driver's License?

If required, would you be willing to obtain a Chauffeurs License?

Whate state?

Do you have any violations in the past 7 years on your motor vehicle record?

Do you have high risk insurance?

Are you currently employed?

EDUCATION/SKILLS: Please list all education beginning with most recent.

Name & Location of School

# of yrs. Complete

Graduated

Degree &/or Major

High School/GED

College

Graduate School

Trade School/Other

REFERENCES: Please list three professional references. By listings these references, CCSI assumes we may contact these people. Do not list relatives.

Name

Address

Business

Phone

EMPLOYMENT HISTORY: List your four most recent positions relevant to the position you are applying for.

Dates Employed (month/year) - If you are presently employed in this position, please leave the ‘To:’ field blank.

Position Title

From:

To:

Salary

Organization Name/Address

Start:

Final:

I was paid:

Employment Type:

Hours worked per week:

May we contact your references?

Supervisor's Name/Title/Phone

Reason for leaving:

Please explain your reason for leaving

Duties:

Dates Employed (month/year) - If you are presently employed in this position, please leave the ‘To:’ field blank.

Position Title

From:

To:

Salary

Organization Name/Address

Start:

Final:

I was paid:

Employment Type:

Hours worked per week:

May we contact your references?

Supervisor's Name/Title/Phone

Reason for leaving:

Please explain your reason for leaving

Duties:

Dates Employed (month/year) - If you are presently employed in this position, please leave the ‘To:’ field blank.

Position Title

From:

To:

Salary

Organization Name/Address

Start:

Final:

I was paid:

Employment Type:

Hours worked per week:

May we contact your references?

Supervisor's Name/Title/Phone

Reason for leaving:

Please explain your reason for leaving

Duties:

Dates Employed (month/year) - If you are presently employed in this position, please leave the ‘To:’ field blank.

Position Title

From:

To:

Salary

Organization Name/Address

Start:

Final:

I was paid:

Employment Type:

Hours worked per week:

May we contact your references?

Supervisor's Name/Title/Phone

Reason for leaving:

Please explain your reason for leaving

Duties:

How did you find out about this job opportunity?

Please state any additional information you feel may be helpful to us in considering your application, i.e., volunteer experience, previous training not listed elsewhere, etc.

Disclaimer & Signature – I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.